Memorial Hospital

Dr. M. S. Guwalani
Care Centre, Dental Clinic, Pathology Laboratory,Medical Store
Family Health
Sector 1-A, Opp. Mahatma Gandhi
Shopping Center, Gandhidhan- Kutch.
370 201.
Plot No. 34,
Dr. Sapna R. Guwalani
Dr. Rajesh M. Guwalani
B.D.S
MD Physician Dental Surgeon
Family Physician
Ph. No. 02836-236478 Date: 11/LL

Name WILSO PiNTO Age:

Hosprbul ch
B1 nD 73
Mead Sh Me
Rakan Mel 3o

i1 h 136 - 11no22

3 l one
UWALA E
MahatmaGandhiMarke
MOR PIO a

Gandhidham(Kutch) 63
Lol 3
JO

LAL So
Tol
PURPOSE
NOT VALID FOR MEDICO LEGAL
 Claim Form 'ASSURE
Part B

Tobe ilkeuir by the hUspit at

he sue of the Formis not to he taken as anainissiotof Fabiit;
kese"'heihe orgnai prr auth yat treyuest himin bcuetIARTA
T en letters

Section ADetails of Hospital

a) Name of the Hosptal CR MSGuNA cNIMEooR I 101p/na
b) Hosprtal 1D

ypeof HOsprtal Network Non-network (f non network fill section E)

d) Nane of the treating doctor
Gol AATE
rst"T)
mNo1HM
e) Qualfication
M D P1i
Regstration No. with State Code

Contact No.
-3
h)
Name and contact details of other doctors whom you have consulted

Name

Contact No. (O):

(R)
Name

Contact No. (O):

(R)
Name

Contact No. (O):

(R
Name

Contact No. (O): (R)

Section B Details of the Patient Admitted
a Name of the Patient WILShNIPINTOV I
(Sum ) rst Nfne) Mdde fm
b)PRegistration No. t02 2
Gender M F
d)Age: e) Date of Birth:

Date ofAdmision S/L s D M 8) Time of Admission: P M ,

Date of Dscharge i) Time of Discharge
Pon
ype of Admission Emengency Planned Day Care Maternity
k)Maternity
Dateof Delivery DO1MYY) )Gravida Status.
S1atus at the time of discharge Discharge to home Discharge to another hospital
Deceased
m) Total Clamed Amount

Section C Details of Ailment Diagnosed (Primary)4

a)Primary Dagnosis ICD 10Code: Description: RAiN- 1K) K
() Addtional Dagnoss ICD 1O Code: Description:
(u) Co-morbidites ICD 10 Code Description
(v) Co-morbidites ICD 10 Code: Description :

D)) Procedure ICD10Code Description

)Procedure 2 ICD 10 Code: Descr ption
u) Procedure 3 ICD 10 Code Description
(v) Detals of Procedure

Religare Health Insurance C'ompany Linuited

Ste e sth Floor, 19 Chawla House. Nehru Place,New Delhi-I10019 Corresp. Office Vipul Tech Square, Tower C, Jrd Floor, Goif Course Rd., Scc-43, Grgaon 122009 (iHaryan)
rligarcbealthinsurance con E-mail. customerfirs@religarchealthinsurance.com Call us: 1800-200-488 / 1860-500-4488
Fax: 1600-200-6677 CIN: U66000DL2007PLC 161 503 UTN: IRDA/NL-HLT/RHIP-H(CyV.UI4/13-14 148
IRDA Registration No.
-
 arcmpl at

Tes
a ataeidHouw

Yes NO
e s gveiause Self nfhcted Road Iraffic Accrdent Substance Abuse/Alcohol Consumption

a y due lo Substan e abuse/Akolhol consumpton Test conducted to establsh ths es No

IYeL alta h repor ts)

H Mede olegal es

exa
ted to Polce

R NO

not rerted to Polce,&ve reason

Section D.Claim Documents Submitted Checklist

Aub ugned Claum orm () Orgnal Pre-authornzation request

y of Pre-author i7aton approval letter (v) Copy of photo ID card of patient verifíed by hosprtal

HOsptalDicharge Summary ()Operation Iheatre notes

Hospital Main Bill (vin) Hosptal Break-up Bill

nvestigation Reports CT/MRUUSG/HPE investgation reports

Doxtor's referenceslpfor investigation (xu) ECG

harmac Bills XIV) MILC report &Polce FIR

Orignal death summary from hospital where applicable (xvi) Any other, please specity

Section E-Details in case of Non-Network Hospital (Only fllin case ofnon-network hospital)
aAddress of the Hospital
S d s R-A PloNo. 34

4AND11DhA)
State URA7 PnCode: 3 /
ContactNo
Regstration No.withState Code
HosptalPAN
AN3ne 7 e) No. ofinpatient beds:

Fac ities avalable nthe hosptal () OT Yes No ) ICU: Yes No

() Others

Section F Declaration by the Hospital

W hereby declare that the information furnished in this Clam Form is true &correct to the best of our knowledge and belef. If we have made anyfalse or untrue
statement. suppression or concealment ofanymaterial fact, our right to claim under this clam shall be forfeited.

Date DMM/YY) Signature & Seal ofthe HospitAuthorit

G U W A L A N I

Place DR.
M. S.
MEMORIAL HOSPITAL

No. 34,
Plot
Sector
1/A, hfarket,
Gandhi
201.
Mahatma
370
B/h. (Kutch)
Religare llealth Insurance Company Limited
sicicu Ollie th Foor, 19 Chawlacom
l louse,E-mail:
Nehnu Place.New Delhi-I 10019 Conesp. Oflice: Vipul Tech Squaie, Tower GJIOr, Golt Cowse Rdl, Sec-43, Gurgaon I22009(llaryana)
-

bsie wWWreligarehealthnsurance customcrlirst@religarchealthinsurancecomm Call us: 1800-200-4488/ 1860-500-4488

ax I800-200-4077 CIN Uo6U00DI 2007PLC 1o1503 UIN: IRDANL-ILT RUP-VUI/13-14 IRDA Registration No. - 148
Page &